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Health Plans

Member forms

For forms and documents related to your health plan, start here.

Looking for Medicare forms?

Visit the Forms Library for documents specific to Medicare, including claims and enrollment forms.

Medicare Forms Library

Claims forms

If you need to submit a medical, vision, and medical supplies claim, you can choose the form you need below:

Medical, Vision, and Medical Supplies Claim Form (PDF)⁠

Formulario de reclamación para afiliados (Spanish) (PDF)⁠

Note: Use the member claim form if you needed health services on a cruise ship.

If you need to submit a prescription drug claim, you can choose the form you need below:

Prescription Drugs Claims Form (PDF)⁠

Formulario de reclamación por medicamentos recetados (Spanish) (PDF)⁠

  • Mail: Prime Therapeutics (Commercial) Mail route BCBSNC
    PO Box 25136
    Lehigh Valley, PA 18002-5136

You may need these claim forms for services received or rendered outside of the US, For benefits received on a cruise ship, please submit the domestic claim forms.

International Claim Form (PDF)

Reclamo Internacional (Spanish) (PDF)

The claim form only applies if your health plan offers a travel benefit. You must sign the form to verify that you traveled out of state for a medical service covered and approved by your health plan.

Member Travel Benefit Claim Form (PDF)

  • Mail: Blue Cross and Blue Shield of North Carolina
    PO Box 35
    Durham, NC 27702-3055
  • Fax: 866-990-1385

You may need to submit a dental claim. You can choose the American Dental Association® (ADA) claim forms based on your type of Blue Cross NC dental plan below:

Need help submitting a claim? Please visit our Member Knowledge Center for detailed instructions.

Learn How to Submit a Claim

Appeals forms

If you need to file a medical appeal, you can choose the form you need below:

Member Appeal Form (PDF)

Formulario de apelación de reclamaciones (Spanish) (PDF)

  • Mail: Member Rights and Appeals
    Blue Cross and Blue Shield of North Carolina
    PO Box 30055
    Durham, NC 27702-3055

You can submit the Member Appeal Representation Authorization Form to choose and give a trusted representative the ability to file an appeal on your behalf. You can find the form and where to send it below:

Member Appeal Representation Authorization Form (PDF)

Formulario de autorización de representación ante apelaciones del afiliado (Spanish) (PDF)

  • Mail: Member Rights and Appeals
    Blue Cross and Blue Shield of North Carolina
    PO Box 30055
    Durham, NC 27702-3055

If you need to file a dental appeal or grievance, you can choose the form you need below:

Dental Appeals and Grievances (PDF)

Dental Apelaciones y Quejas (Spanish) (PDF)

  • Mail: Member Rights and Appeals
    Blue Cross and Blue Shield of North Carolina
    PO Box 2100
    Winston Salem, NC 27102-2100
  • Fax: 336-714-0224

For more information on submitting an appeal, please visit our Member Knowledge Center.

Learn How to File an Appeal

Coverage forms

Allows members and their dependents to continue receiving care from a provider who is no longer in the Blue Cross and Blue Shield of North Carolina (Blue Cross NC) network.

Continuity of Care Form (PDF)

  • Mail: Blue Cross and Blue Shield of North Carolina
    Care Management
    PO Box 2291
    Durham, NC 27702-2291
  • Fax: 800-228-0838

You have the right to give a caregiver, loved one, or trusted person access to your protected health information (PHI). In order to do so, you need to give Blue Cross NC written authorization.

Parents or guardians of dependent children over 18 (or between the ages of 14-18 for certain diagnoses) will also need their dependent to provide authorization before we can share their PHI with you.

You can print, complete, and mai,l or fax the Authorization Request Form (PDF), 

  • Mail: Commercial Operations / IDC
    Blue Cross and Blue Shield of North Carolina
    PO Box 2291
    Durham, NC 27702-2291
  • Fax: 800-228-0838

You can also submit online through your Blue Connect member portal. 

 

Certifies a dependent child has lost their student status at a postsecondary educational institution due to a leave of absence caused by a serious illness or injury. You may be able to continue their coverage. A physician must complete this form.

Student Leave of Absence Certification Form (PDF)

Solicitud de autorización del afiliado (Spanish) (PDF)⁠

  • Mail: Blue Cross and Blue Shield of North Carolina
    Manager Enrollment and Billing Operations
    PO Box 2291
    Durham, NC 27702-2291

 

You can request a certificate for terminated (ended) policies from Blue Cross NC for up to 24 months following termination. If your policy is still active, and you need a Certificate of Creditable Coverage document, please call the Customer Service number on your Blue Cross NC member ID card.

To submit an online request or change, you must be a member of the reference Blue Cross NC health plan, or a group benefits administrator authorized to make requests or changes on the member's behalf. Following receipt of your request, you will receive your proof of coverage certificate through regular mail within 10 days.

Health coverage tax form 1095-B

This form was created to show proof of health insurance for the individual mandate, which no longer exists. Consult your tax advisor for questions, as this form may not be needed.

We stopped mailing out this form, but you can download a copy through Blue Connect℠. If you don't access it through Blue Connect, please allow up to 30 days for us to send you a copy.

You can get a copy of form 1095-B in several different ways (Note that some restrictions apply and paper copies must be mailed in certain states):

If you would still like a copy of Form 1095-B, you can get a copy from Blue Connect.

Log In to Blue Connect

Don't have an account yet? Register for Blue Connect now.

Call us to request a copy:  800-326-0052

Request a copy via email: TaxFormRequest@bcbsnc.com

Please be aware that e-mail communication can be intercepted in transmission or misdirected. If you are uncomfortable with sending your health information via unsecured email, please consider communicating by using one of the other methods of on this page.

Please include the following information in your email to us:

  1. Name (as it appears on your member ID card)
  2. Email address
  3. Member ID
  4. Date of birth
  5. Home mailing address

By sending an email to this address, I am affirmatively consenting to receive my 1095-B Form via email and understand by doing so that I will not receive a paper copy of Form 1095-B unless I specifically request one. As a convenience to me, I hereby request and authorize Blue Cross and Blue Shield of North Carolina (Blue Cross NC) to provide me with this form electronically. I understand that it is my responsibility to ensure Blue Cross NC has my up-to-date email address and that it is in fact correct and accurate. I further understand that I am solely responsible for ensuring my email address is functioning properly at all times and that Blue Cross NC has no liability for errors in transmission of the electronic Form 1095-B other than addressing the electronic form to the email address I provided. I acknowledge and agree that the date of receipt of my electronic Form 1095-B shall be the date and time on which I requested it, regardless of the date and time I actually receive and/or review this form.

Send a request in writing to Customer Service:

Blue Cross NC
ATTN: IRC6055
PO Box 2291
Durham, NC 27702